New Client Form | South Loop Animal Hospital & East Side Veterinary Clinic

Are you thinking about visiting us soon? Request an appointment on this page for the date and time that is most convenient for you! Keep in mind that we will do our best to meet your time slot request but sometimes we have conflicting schedules. Please hold tight, and our team will reach out to confirm your appointment soon!

Select Location

Your Name

Home Address

Cell Phone #

Work Phone #

How Can We Help?

Co-Owner Name

Co-Owner Phone

My pet's co-owner relationship

Emergency Contact Name

Emergency Contact Phone

How did you find out about our hospital?

Pet's Name

Species

Breed

Color (specific markings)

Date of Birth (approximate age if date unknown)

Sex

Spayed/Neutered

Microchipped

Diet (Brand of pet food, treats, human food given, etc.)

How much and how often do you feed your pet?

Does your pet have any food intolerances/allergies?

Does your pet have contact with other animals?

Does your pet live indoors, outdoors, or both?

Does your pet travel with you often?

MEDICAL HISTORY

Please provide our receptionist with copies of your pet's most current medical records and your previous veterinarian's contact information.

Are your pet's vaccinations up to date?

When/where were they given?

Does your pet have any drug or vaccine allergies?

Please list any existing medical conditions:

Is your pet current on any medications?

AUTHORIZATION

<br
In admitting my pet(s) for examination, diagnostics, treatment, or surgery, I authorize the veterinarians of South Loop Animal Hospital, and their support staff, to administer such treatment and/or perform such diagnostic or surgical procedures as deemed necessary. <br
I assume responsibility for all charges incurred in the care of my pet. I understand that professional fees are to be paid at the time services are performed. Further, a 50% deposit is required for hospitalization and/or surgical treatment. We will gladly prepare an estimate of frees at your request. <br
Methods of payment we accept: <br
Visa, MasterCard, Care Credit, Cash, and Checks

I agree to the above terms and conditions

Name